The pharmacy fee schedule is based on Wolters Kluwer Medispan Electronic Drug file wholesale acquisition cost (WAC) or the organization's pharmacy benefit management company's maximum allowable cost (MAC), when applicable.
- The lesser of maximum allowable cost (MAC) plus 5% or WAC plus 8%, plus a single per item dispensing fee of $5.00 or usual & customary (URC) pricing
- MAC pricing is based on the most current MAC list provided by WSI's PBM
- Reimbursement is the lesser of billed charges or the fee schedule amount
- Reimbursement is at the WAC plus 8%, plus a single per item dispensing fee of $4.00; or the UCR pricing
- Reimbursement is the lesser of billed charges or the fee schedule amount
Compounded prescriptions are reimbursed at the average wholesale price (AWP) minus 72%, plus a single item compounding fee based on the following level of effort (LOE) level or the UCR pricing:
| Compound LOE | Value | Reimbursement |
|
Level 1 Mixing liquids using graduated cylinders |
11 | $ 10.00 |
|
Level 2 Triturate powder and mix by geometric dilution, mix creams, ointments, emulsions and liquids by hand or by using unquator |
12 | $ 15.00 |
|
Level 3 Suppository mold, lollipop mold and troche/mini-trouche mold, dissolve powder using stirrer and hot plate, melt base on hot plate, burette and/or pH meter, making capsules using filling machine |
13 | $ 20.00 |
|
Level 4 USP 797, sterile compounding using hood |
14 | $ 25.00 |